Dermatomycoses:

from head to toe

 Five kingdoms of living world
• Planta
• Animalia
• Fungi (eukaryotes - dermatophytes, yeast-like,
moulds)
• Protista (protozoa, algae, tripanosomes, etc.)
• Monera (prokaryotes, bacteria).
 PROLOGUE: A BIOLOGICAL GUIDE
• Fungi are everywhere.
• There are some 1.500.000 known species.
• About 200 species a pathogenic for humans.
• Eukaryotic cells (contain nuclei and organelles)
• Heterotrophic - fungi lack chlorophyll and are therefore
not photosynthetic like plants and algae
• Saprophytes (living on dead organic matter) or
parasites (utilizing living tissue).
• Rigid cell walls (have chitin not murein like bacteria)
and are therefore non-motile, like plants.
 FORM AND REPRODUCTION
• Fungal cells are eukaryotes with a single set of genetic
material (haploid).
– multicellular (dermatophytes), reproduction through
sporulation, adult cells are separated completely and form
filamentous structures (hiphae); the totality of hyphae =
micelium (thalus): Microsporum, Trichophyton,
Epidermophyton.
– unicellular (yeast-like), reproduction through budding,
resulting daughter cells incomplete separated, forming
pseudohyphae and pseudomicellium: Cryptococcus
neoformans; Candida spp.
– dimorphic (moulds, micromicetes), two growing forms:
filamentous as in multicellular fungi at 22ºC (saprophytic
phase) and yeast-like at 37ºC (parasitic phase): Aspergilus,
Blastomyces, Coccidioides, Histoplasma capsulatum, etc.
 Dermatophyte cycle: spores-hyphae-micelium-spores
Yeast cycle: blastospores-pseudomicelium-chlamydospores blastospores
 CLASSIFICATION OF THE FUNGI

• A definitive classification is not possible until the

perfect stage has been identified and described.
The classification is arranged in six groups (see
table), three of which are relevant to disorders
in human beings.
• The last group, Fungi Imperfecti, is a group with
no identified sexual reproduction and whose
perfect stage is therefore unknown.
• The actinomycetes are gram-positive bacteria
which cause, inter alia, pseudomycoses.
CLASSIFICATION OF THE FUNGI
 FUNGAL PATHOGENICITY
• The two major physiologic barriers to fungal growth within
the human body are temperature and redox potential.
Most fungi are mesophilic (10-20oC) and can not grow at
37oC. Similarly, most fungi are saprophytic and their
enzymatic pathways function more efficiently at the redox
potential of non-living substrates than at the relatively
more reduced state of living metabolizing tissue.
• In addition, the body has a highly efficient set of cellular
defences to combat fungal proliferation.
• Thus, the basic mechanism of fungal pathogenicity is its
ability to adapt to the tissue environment and to withstand
the lytic activity of the host's cellular defenses.
• In general, the development of human mycoses is related
primarily to the immunological status of the host and
environmental exposure (warm and moist conditions),
rather than to the infecting organism.
 DERMATOMYCOSES –
DEFINITION AND CHARACTERISTICS
• Dermatomycoses are infections of the skin, hair or nails by fungi.
• The principal causative agents are dermatophytes, which are
subdivided into three groups (genera):
Trichophyton: thin-walled, smooth, four to six septa
Microsporum: thick-walled, with projections five to more septa
Epidermophyton: thick-walled, oval shaped four or fewer septa

• Besides the dermatophytes, yeasts are also capable of causing skin

disorders - Candida spp. and Pityrosporum.
• Infections are increasingly being caused by species of fungus which are
classified neither as yeasts nor dermatophytes – moulds. An example
of this is Scopulariopsis brevicaulis, which can occur in nails.
Etiological classification of dermatomycoses

Dermatophytons of 3 genera: Trichophyton,

Microsporum and Epidermophyton

Keratophytons of some yeast species: Pityrosporum

ovale, Pityrosporum orbiculare, Malassezia furfur.

Candida genus (Candida albicans and non-albicans spp).

Pseudofungi (Corynebacterium minutissimum,

Actinomyces israelii, etc).

Moulds (Scopulariopsis, Aspergillus, Penicillium, etc.)

DERMATOPHYTES - CLASSIFICATION
 DERMATOPHYTES – THEIR HOST
• On the basis of the original host, a distinction is
made between
• anthropophilic,
• zoophilic (zooantropophilic)
• geophilic

• Zoophilic dermatophytes in human beings frequently

evoke a more intense inflammatory reaction than an
infection by anthropophilic species.
• Dermatophytes have a preference for growth in and
around the hair, in the horny layer of skin, in the
moist, warm folds of the skin, or just under the nails.
• Keratinophilia is a major characteristic of
dermatophytes; they only grow in the dead, horny
layer of the skin, hair and nails.
 3 dermatophyte genera:
species and diseases
Trichophyton
T.violaceum, T.tonsurans (antropophilic trichophyton
superficial Tinea); T.verrucosum, T.gypseum
(zooantropophilic trichophyton deep Tinea);
T.schoenleini (favus); T.rubrum (rubromycosis); T.
menthagrophytes var. interdigitale (Tinea plantaris).
Microsporum
M.ferrugineum, M.audoini (antropophilic microsporum
Tinea); M.canis, M.nanum (zooantropophilic
microsporum Tinea).
Epidermophyton
E.floccosum (Tinea cruris).
 DERMATOPHYTES –
THEIR ANIMAL HOST
DERMATOPHYTES AND THE SKIN
DERMATOPHYTES AND THE NAILS
Endothrix spore growth
Small-spored ectothrix growth
Large-spored ectothrix growth
 Summary of the different forms
of growth of dermatophytes in hair
 YEASTS
• The two major species of yeast capable of causing
skin infections are Candida albicans and
Pityrosporum ovale.
• The most striking property of these yeasts is that
they are commonly part of the normal flora - real
opportunists.
• Particular importance attaches to predisposing
factors.
• There are various predisposing factors which are
conducive to the transition from commensal to
pathogenic; a moist skin, a high pH and the presence
of sugars and certain amino acids create a favourable
climate for Candida.
Pseudohyphae of C.albicans
(in vaginal mucosa of rat)
 PITYROSPORUM
• It is a lipophilic yeast which only grows when oil, glycerin
or glyceryl monostearate is added to the culture medium.
Pityrosporum is chiefly found as a commensal on areas of
the skin containing a relatively large number of sebaceous
glands.
• The yeast can assume various morphological forms. Until
quite recently this led to the assumption that
Pityrosporum ovale, Pityrosporum orbiculare and
Malassezia were three different organisms. Now,
however, it is known that they are different forms of
growth of one and the same yeast: P. ovale.
• It has recently been established that P. ovale also plays a
role in seborrhoeic dermatitis. Patients with this infection
have a high concentration of P. ovale on the skin, as a
result of which inflammatory reactions occur. Dandruff is
regarded as a form of seborrhoeic dermatitis.
 DERMATOMYCOSES - CLASSIFICATION
• Dermatomycoses can be classified in various ways. The simplest of all
would seem to be a systematic arrangement on the basis of the
causative agents. In a classification of this nature, the disorders are
designated by reference to the individual genus: trichophytosis,
epidermophytosis, microsporosis, candidosis (candidiasis) and
pityrosporosis.
• A classification focused more on the epidemiology and method of
dissemination is one that is based on the original host of the various
fungi. This produces such terms as anthropophilic, zoophilic and
possibly geophilic agents: fungi which therefore have human beings,
an animal or the soil as their primary habitat.
• Closer to actual practice is a classification on the basis of the clinical
picture, designated, for example, by the severity of the inflammation:
mild, moderate or severe.
• The most widely used classification is largely based on the site of the
clinical picture. As mentioned earlier, the largest group of
dermatomycoses consists of disorders which are caused by
dermatophytes - TINEA.
DERMATOMYCOSES
 Dermatophytoses = Tinea
There are 5 Dermatophytoses by etiology:
• Epidermophytosis,
• Rubromycosis,
• Trichophytosis,
• Microsporosis,
• Favus

There are 5 Tinea by site (WHO ICD-10)

• Tinea pedis et Tinea manum (soles and palms);
• Tinea cruris (inguinal fold)
• Tinea corporis (glabrous skin);
• Tinea unguium (nails);
• Tinea capitis, Tinea barbae (scalp, face, beard,
moustaches)
REFERENCE SYSTEM FOR THE
DERMATOMYCOSES
Clinical presentation – general rule
Usually,
the esential primary lesion in
dermatomycoses is erythema and the
secondary are scales, that means
erythemato-scuamous eruption; in exudative
forms primary can also be vesiculous and in
infiltrative forms can be nodular, thus other
secondary lesions can be erosive or ulcerative.
 TINEA CAPITIS
In tinea capitis, also called ringworm of the scalp, the
lesions are typically ring-shaped and the skin and
hair are infected. The hairs break off and leave bald
patches.

Four subgroups of tinea capitis can be distinguished:

• - Microsporosis
• - Trichophytosis (herpes tonsurans)
• - Favus
• - Kerion
TINEA CAPITIS
 Microsporum
Tinea capitis
• Zooantropophilic (M.canis, M.nanum):
erythema, 1-3 foci, of 3-5 cm diameter,
scuamous, round, with sharp limits; the hairs
shafts cut-off uniformly at 5-8 mm from the skin
level.
• Antropophilic (M.ferrugineum, M.audoini):
multiple erythematous foci with smaller diameter,
scaling is less, the hairs shafts cut-off
nonuniformly at 5-8 mm from the skin level.
Zooantropophilic Microsporum Tinea capitis
 Tinea capitis: antropophilic
micrsoporum (M.ferrugineum)
Tinea faceis: antropophilic microsporum
 TRICHOPHYTOSIS
• Children are especially prone to attack by trichophytosis or
herpes tonsurans, in adults - usually females;
• The major causative agents of herpes tonsurans are
Trichophyton tonsurans and T. violaceum.

• Clinical presentation:
– Children form: multiple, small erythematous patches
with tiny adherent scales, hair shafts are broken at 1-3
mm from skin surface spontaneous healing can occur
after puberty.
– Adult female chronic form: black dots, comedo-like,
broken off hairs at the surface of the skin and are only
visible as a small stub, some atrophy and occult scaling.
TRICHOPHYTOSIS
 FAVUS
• Favus is caused by Trichophyton schoenleinii
• Three clinical forms: scutular (typical), impetiginous and
pityriasiform
• Begins as a red scaling patch on the scalp which develops until it
covers an area several centimetres in diameter.
• The next stage is the formation of scutula: yellow, cup-shaped
crusts with a diameter of one to two centimetres.
• A salient feature is that the hairs are not broken off from the
beginning, but the hairs lose their gloss and are arranged on the
scalp in irregular tufts.
• As the patch increases in size, total and irreversible hair loss
occurs in the central region.
• The 'mouse smell' is mentioned in all textbooks.
• The impetiginous form of favus is characterized by moist crusts
with underlying accumulations of pus.
• The pityriasiform (scaling) form is dominated by erythema and
scales.
FAVUS
 KERION
• Kerion occurs at all ages. The causative agents of
this disorder are Trichophyton verrucosum or
T. mentagrophytes var. gypseum.
• Kerion begins as an erythematous annular patch
which gradually elevates itself above the
surrounding skin. It is clearly circumscribed,
while the slightly nodular surface is covered with
pustules. Pus is released when pressure is
applied (honeycomb sign). It is associated with
occasional pain. A kerion infection is not
restricted to the scalp. Infections of this nature
are also possible in the beard area.
• If left untreated, the condition will persist for
several weeks or months. Then the symptoms
will gradually diminish. An atrophic scar may
remain after healing, while the sustained hair
loss will not be fully replaced. However,
superinfections can seriously complicate this
relatively benign process.
KERION
Kerion Celsi
 TINEA BARBAE
• T. gypseum (mice) or T. verrucosum (cows).
• Tinea barbae is also called trichophyte (parasitic)
sycosis.
• Tinea barbae and tinea capitis are one and the same
infection.
• Kerion also occurs in association with tinea barbae.
• The infection can last for months and there is a real
risk of bacterial superinfection.
TINEA BARBAE
 TINEA CORPORIS
• Every dermatophyte can be the causative agent of tinea
corporis: Microsporum spp., Trichophyton spp. and
Epidermophyton floccosum.
• Tinea corporis, formerly called herpes circinatus, is a tinea or
ringworm disorder of glabrous skin.
• Annular scaling erythematous patches, slowly expanding edge
with inflammation which is frequently somewhat elevated.
• The lesions are clearly circumscribed and vesicles may also
occur.
• The patient may also complain of itch and a burning sensation.
• The lesion spreads peripherally and tends to heal in the centre.
• After several months, depending in part on the species of
fungus involved, spontaneous healing can occur.
• Chronic infections are also possible, however, and T. rubrum
infections are notoriously obstinate.
TINEA CORPORIS
TINEA CORPORIS
 TINEA CRURIS
• Caused by Epidermophyton floccosum or
Trichophyton rubrum.
• Tinea cruris is more common in men than in women,
probably because the male population is also more
susceptible to tinea pedis.
• Tinea cruris begins with arcuate erythematous
plaques in the perineal fold which spread to the
thighs.
• Itch and a burning sensation are the patient's major
complaints.
• Scaling is not always present and vesicles are rare.
• The scrotum may also be affected, while T. rubrum
can spread to the anal region and the abdomen.
TINEA CRURIS
TINEA CRURIS
 TINEA PEDIS PLANTARIS
AND TINEA MANUS PALMARIS
• The causative agents are the same as in tinea pedis. The
relevant fungi are therefore Trichophyton
mentagrophytes var. interdigitale, T. rubrum and
Epidermophyton floccosum.
• Athlete's foot
• Dermatophyte infections of the palm and sole show
erythematosquamous eruption.
• These are frequently attended by deeper, brownish
pustules.
• After they have broken, they dry up with considerable
scaling.
• The course of the infection is quite often chronic.
TINEA PEDIS PLANTARIS AND TINEA MANUS
PALMARIS
 Tinea pedis et Tinea manum
clinical forms
• Dyshidrotic vesiculous form

• Scuamous hyperkeratotic form

• Intertriginous (interdigitalis) form

 Tinea pedis,
dyshidrotic form
 Tinea pedis,
dyshidrotic form
 Tinea pedis,
hyperkeratotic form
 Tinea pedis,
hyperkeratotic form
 Tinea pedis,
hyperkeratotic form
Tinea pedis, intertriginous form
TINEA MANUS PALMARIS
TINEA MANUS PALMARIS
Tinea manus
 TINEA UNGUIUM
• The principal agent is Trichophyton rubrum, however,
Epidermophyton floccosum, Trichophyton menthagrophytes,
T.tonsurans and T.schoenleinii can also be the causative agent.
• Atrophy (onycholysis), discoloration and subungual
hyperkeratosis.
• Three clinical forms: normotrophic, hypertrophic and atrophic
• Onychomycosis may be the patient's only disorder, but in many
cases the skin is also affected (tinea pedis).
• The initial lesion is small and consists merely of a discoloured
spot (yellow or white). As it grows towards the base of the nail,
this is attended by more discoloration (brown or black) and the
nail is raised.
• The nail becomes brittle and friable. Onycholysis can occur and
the entire nail plate can be destroyed. Although it usually starts
with just one nail, after some time other nails are also frequently
infected.
Tinea unguium clinical forms
 Tinea unghium:
distal/lateral subungual onychomycosis
 Tinea unghium:
distală/laterală subunghială
 Tinea unghium:
superficial white onychomycosis
 Tinea unghium:
proximal subungual onychomycosis
 CANDIDOSIS
• Candida albicans is the most widely known and most
pathogenic species of yeast.
• C. albicans is normally present as a commensal in human
beings, especially in the gastrointestinal tract and also in
the vagina.
• Candida infections are most often found in the large and
small flexure lines; this is frequently referred to as
intertrigo.
• Erythema, which has a quite dark red colour, and
exudation occur deep in the crease or fold, on the
apposed surfaces of the skin.
• The skin is severely macerated and erosions may develop.
• Small 'islands off the coast', or satellite lesions, and
pustulation may also be present.
• The patient often experiences itch and a burning pain.
•
 Candidosis
Candidosis of mucous membranes
– Oral candidiasis (stomatitis)
– Angular cheilitis
– Cheilitis
– Vulvo-vaginitis
– Urethritis and balano-posthitis .
Candidosis of the skin
– Intertrigo
– Paronychia and onychia
– Erythroderma
Chronic muco-cutaneous candidosis
– Oral chronic
– Endocrine
– Diffuse chronic
– Granulomatous.
Visceral (systemic) candidosis
Oral candidosis / angular cheilitis
Candida vulvo-vaginitis
Candida balanoposthitis
Candida intertrigo
Candida intertrigo
Candida paronychia and onychia
Candida paronychia and onychia
Granulomatous candidiasis
 PITYRIASIS VERSICOLOR
• Pityrosporum ovale, Pityrosporum orbiculare, Malassezia furfur
– the same agent
• Is dependent upon oil or fat for its growth. This yeast species is
always present on the skin of human beings as a commensal,
especially in ear wax, on the scalp and at other sites where
many sebaceous glands are present.
• Pityriasis versicolor is a disorder which is particularly noticeably
because of the discoloration of the skin.
• By comparison with untanned skin the patches are darker, but
on tanned skin they are lighter. The colour can vary from yellow
to brown, red or whitish.
• After some time the patches coalesce.
• A second major characteristic is the very fine scaling, which is
sometimes only apparent after scraping with a spatula. 'Pityron'
is Greek for 'bran'.
• Patients are usually not so susceptible to itch or inflammation.
• Positive Balzer (iodine) sign.
PITYRIASIS VERSICOLOR
PITYRIASIS VERSICOLOR
PITYRIASIS VERSICOLOR
Iodine Balzer test
 LAB in mycology

• Direct microscopy (KOH 20%)

• Culture on selective media (2-4 weeks)
• Wood’s lamp examination (fluorescence)
• Histopathology = PAS staining
 Candida albicans:
celule levurice înmugurite
Sampling - scraping the edge of the lesion
for microscopic examination
Trichophyton mentagrophytes
Trichophyton rubrum
Epidermophyton floccosum
Aspergillus fumigatus
 Culture on selective media
• Disclose the fungus implied
• Sabouraud media – classic for growing fungi :
– glucose 4 g,
– peptone 1g,
– agar 2 g,
– distilled water 100 ml.
• Mycograma – to reveal drug resistance.
Culture: a) T.rubrum; b) E.floccosum; c)
T.mentagrophytes; d) M.canis
WOOD’s lamp
 Main systemic antifungals
• Poliens:
Amphotericine B (1956)
Nystatine (1951)
• Miscellaneous:
Flucytosine (1957)
Grizeofulvine (1958)
Potassium iodide (1811)
• Azoles:
Imidazole – Myconazole (1969); Ketokonazole (1977)
Triazoles – Itraconazole (1980); Fluconazole (1982)
• Alilamines:
Terbinafine
• Morfolines:
Amorolfine (1989)
 Local treatment
1. Local antifungals: sulfur ointment 5-10%, iodine solution 2-
5%, Castellani solution, methylen blue solution 2%,
clotrimazole, miconazole, econazole, ketokonazole (nizoral),
natamycin (pimafucin), ciclopiroxolamine (ciclopirox,
batrafen), terbinafine (lamisil), bifonazole (micospor),
naftifine (exoderil).
2. Keratolytics (in fungal hyperkeratosis): salicylic acid ointment
3-5-10-20%, Arievich ointment (lactic/salicylic acid),
Whitefield ointment (benzoic/salicylic acid).
3. Keratoplastics (in fungal infiltrates): ichthyol ointment 10%,
tar ointment 3-5%, naftalan ointment 3-5%.
4. Wet to dry lotions with antiseptics (in fungal exudates):
d-Alibur sol., ethacridine lactate sol., potassium
permanganate sol., furacilin sol., tannin sol.